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��CKWATER PREVEfVTIOfV DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: /+Poi �0 1�/� .� /7 �n � ��/zs) ? 5 �-- /S� 7 <br />Date Backvrater Prevenfion dewce (BWD) �vas insialled:___ j��3/ir Date this form was compleled: �,s" /.S� <br />Instaliz!ion Prcperfy Owner Name and Contacf Irdo: P�..a /.u�r �'�� <br />ProperyAdtlress: lyio �s'" s f <br />Pre-Instaliatfon Inspection Checklist: ' <br />AI! items must be checked 'Yes' in ord?r (or a 2WD fo de considered for inslallafion <br />Is there ; bzsemeni or level of the hc�se that is at or near assumed sewer main elevation? [�Yes ❑ No <br />Are there fixtures in the house locatetl below the upstream set�;er manhole rim elevaiion? [zi Yes ❑ No <br />Is the side se�.ver currently UNPROTECTED from seeder backups (does not have a BWD insL?I!ed)?�/ Yes ❑ ho <br />Site inspection Checklisf: <br />A!I ifems must he checkeo `Yes' be(ore inspection is considered complete <br />Vt�as side sewer N insp2cfed trom building to se�ver main? (� Yes ❑ No Condition: <br />Does side setver have at least 1°'o slope from the bui!tling to sev+er main? [� Yes ❑ No Describe: <br />Have all building se�+�zr drain cronneciions fo (he side se��aer been identified and located? ,�Yes ❑ No <br />Have all property storm drainage connections to lhe side se���er been identified and located? �Yes ❑ No <br />Has proparty oeen evaluated for drainage deficiencies wi!h findings communicai2d to propaNy owner? � Yes rj No <br />Installation Details: �---� <br />Wha[ type and tirand o( BVJD was i istalled at this� ean Chei ck BNN' inder pump, etc.): <br />Where v�as the device inslalled f�eneral description, atlach map)? <br />lNas thzre ary oiher se�ver or storm drainaae tia�ork comple;ed in conjunction �.vilh the BIA�D ���crk? Is so please describA: <br />Instailation Checklist: <br />Are all dowaspouts antl site drainage disr.�nnectzd irom upstream of lhe 8WD? � Yes ❑ No Commenis: <br />Does BWG positioning meets minimum slope requiremenf of >1%? � Yes ❑ No Comments: <br />Can BWD be pulled out (or inspection and mainlenance afler loosening thumb screw?�] Yes ❑ No <br />Is 8WD locked inlo the propzr posilion and thumb screw iightened? �Yes ❑ No <br />Cirde ih� BWD cover: irrigation cove� . � rea) I UaffiC �ra 'oearing cover (drive suriace) I access hatch (building) <br />VJas property owner sh�wn ihe location of e installed DWD? �i Yes ❑ �b Commenis: <br />%' T i <br />Property bwners Signature• %� C�-�'� Date: ///3,�i� � <br />Installer's <br />Date: 1��3�Z�iJ" <br />Revision: 2 1 Monday, September 15, 2014 <br />